BACKGROUND: There is a paucity of data to describe advanced forms of cardiovascular disease (CVD) in urban black Africans with hypertension (HT). METHODS: Chris Hani Baragwanath Hospital services the black African community of 1.1 million people in Soweto, South Africa. We prospectively collected detailed demographic and clinical data from all de novo presentations to the hospital's Cardiology Unit in 2006. RESULTS: Overall, 761 black African patients (56% of de novo cases) presented with a diagnosis of HT with more women (63%, aged 58.5±14.9 years) than men (aged 58.0±15.6 years). On presentation, 396 women (82%) versus 187 men (67%) had dizziness, palpitations and/or chest pain (OR 1.23, 95% 1.12-1.34: p<0.0001). HT was the primary diagnosis in 266 cases (35%). In the rest (n=495), non-ischaemic forms of heart failure were common (54% of total) while only 6.2% had coronary artery disease. Concurrent left ventricular hypertrophy, renal dysfunction and anaemia were present in 39%, 24% and 11% of cases, respectively, with a similar age-adjusted pattern of co-morbidity according to sex. However, men were more likely to present with impaired systolic function (OR 2.13, 95% CI 1.50 to 3.00; p<0.0001). CONCLUSIONS: In the absence of effective primary and secondary prevention strategies, these unique data highlight the potentially devastating impact of advanced forms of hypertensive heart disease in urban black African communities with more women than men affected.